Provider Demographics
NPI:1821162355
Name:EMMANUEL MEDICAL SUPPLY CO
Entity Type:Organization
Organization Name:EMMANUEL MEDICAL SUPPLY CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HAESUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-529-2364
Mailing Address - Street 1:31260 PACIFIC HWY S
Mailing Address - Street 2:STE 8
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-5448
Mailing Address - Country:US
Mailing Address - Phone:253-529-2364
Mailing Address - Fax:253-529-2364
Practice Address - Street 1:31260 PACIFIC HWY S
Practice Address - Street 2:STE 8
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5448
Practice Address - Country:US
Practice Address - Phone:253-529-2364
Practice Address - Fax:253-529-2364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6009914Medicaid
1318540001Medicare NSC